University of Texas at Tyler
Scholar Works at UT Tyler
Nursing Theses and Dissertations School of Nursing
Spring 5-3-2012
The Effect of Guided Observation on Learning
Outcomes in Simulation-Based Learning
Jamil Norman
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Recommended Citation
Norman, Jamil, "The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning" (2012).Nursing Theses and Dissertations.Paper 27.
THE EFFECT OF GUIDED OBSERVATION ON LEARNING OUTCOMES IN SIMULATION-BASED LEARNING
by
JAMIL NORMAN, PhDc, RN
A dissertation submitted in partial fulfillment of the requirements for the degree of PhD in Nursing
Department of Nursing
Kathy Missildine, PhD, RN, CNE Committee Chair College of Nursing and Health Sciences
The University of Texas at Tyler May 2012
The University of Texas at Tyler Tyler, Texas
This is to certify that the Doctoral Dissertation of
JAMIL NORMAN, RN
has been approved for the dissertation requirement on March 23, 2012
for the degree of Doctor of Philosophy in Nursing.
Approvals:
Dissertation Chair: Kathy Missildine, PhD, RN, CNE
Member: Carol Kilman, PhD, CPNP, RN
Member: Shelly Marmion, PhD
Member: Kim Leighton, PhD, RN
Chair, Department of Nursing
Acknowledgments
I wish to thank my husband Jack and my daughter Jillian for being with me throughout this journey. I want to thank my family for their love and support. A special thank you to my nursing mentors who instilled the values of the profession of nursing in me. I would like to acknowledge the excellent faculty and staff at The University of Texas at Tyler, especially my chair Dr. Kathy Missildine, thank you! Last but not least, my PhrnDz! Only the chosen transform from friend to PhrnD. I would like to acknowledge Sharon Thompson for her vision on the 2-minute drills. This dissertation is dedicated to my PhrnD Sharon Thompson and my mother Geraldine Bell may they rest in peace and in love.
Copyright
© Copyright by Jamil Norman 2012 All rights reserved
i Table of Contents List of Tables ... iv List of Figures ... v Abstract ... iv Chapter 1: Introduction ... 1
Introduction of the Articles ... 1
The 2-Minute Drills: Incorporating Simulation into a Large Lecture Format ... 2
The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning ... 3
Chapter 2: The 2-Minute Drills:Incorporating Simulation into a Large Lecture Format ... 5
Abstract ... 6
The 2-Minute Drills: Incorporating Simulation into a Large Lecture Format ... 7
Background and Significance ... 8
Theoretical Framework ... 8
Implementation of 2-Minute Drills ... 9
Preparation ... 9
Student and Faculty Experiences ... 12
Conclusion and Recommendations ... 13
References ... 15
Chapter 3: The Effect of an Observation Guide on Learning Outcomes in Simulation-Based Learning ... 19
Abstract ... 20
The Effect of an Observation Guide on Learning Outcomes in Simulation-Based Learning ... 21
Background and Significance ... 22
Theoretical Framework ... 26
Method ... 28
Data Collection Procedure ... 28
Instruments/Measures ... 29
Results ... 30
ii
Data Analysis ... 31
Differences in Satisfaction, Self-Confidence, and Collaboration ... 31
Discussion ... 32
Limitations ... 34
Implication for Future Research ... 35
Conclusion ... 36
References ... 37
Chapter 4: Summary and Conclusion ... 46
Evaluation of the Project ... 47
Knowledge ... 47
Self-Confidence ... 48
Satisfaction ... 48
Collaboration ... 48
2-Minute Drills ... 48
Recommendations Based on the Findings ... 49
Conclusion ... 50
References ... 51
Appendix A: Letter of Inquiry Nursing Education Perspectives ... 53
Appendix B: Letter of Inquiry Clinical Simulation in Nursing ... 54
Appendix C: Observation Guide ... 55
Appendix D: University of Texas at Tyler Institutional Review Board Approval ... 56
Appendix E: University of Central Arkansas Institutional Review Board Approval ... 57
Appendix F: University of Louisiana Monroe Institutional Review Board Approval ... 58
Appendix G: Grambling State University Institutional Review Board Approval ... 59
Appendix H: Human Patient Simulation Pre-briefing ... 62
Appendix I: Human Patient Simulated Scenario ... 63
Appendix J: Facilitated Debriefing ... 66
Appendix K: HESI Exam Results ... 67
Appendix L: Letter of Permission to Conduct Research ... 70
Appendix M: Letter of Permission to Use Instrument ... 71
iii
Appendix O: Qualtrics Survey ... 73
Appendix P: Recruitment Letter ... 80
Appendix Q: Informed Consent to Participate ... 81
Appendix R: Biographical Sketch ... 85
Appendix S: Manuscript Guidelines Clinical Simulation in Nursing ………...88
iv List of Tables
Table 1: Demographic Information (n = 119)... 43 Table 2: Mean Pretest and Posttest HESI Scores (n=121) ... 44 Table 3: Satisfaction, Self-Confidence, and Collaboration (n = 119)... 45
v List of Figures
Chapter 2
Figure 1: The Nursing Education Simulation Framework ... 19 Chapter 3
vi Abstract
SIMULATION-BASED LEARNING: ENGAGING THE STUDENT OBSERVER Jamil Norman PhD(c), RN
Kathy Missildine, PhD, RN, CNE Committee Chair The University of Texas at Tyler
May 2012
Nurse educators have been faced with the challenge of providing adequate clinical preparation for nursing students. Implementation of simulation-based learning (SBL) has been used to meet these challenges. Current research indicates that students and faculty are both satisfied with simulation; however, faculty concerns with improving student learning during SBL have led to a research intervention on the use of an Observation Guide. The purpose of this research was to examine differences in knowledge, self-confidence, satisfaction, and collaboration between baccalaureate nursing students using an Observation Guide when observing a simulated clinical experience (SCE) and those observers without an Observation Guide. Additionally, to meet the challenges of large class sizes and decreases in faculty, the 2-minute drills were formulated to incorporate SBL into the large lecture format. The purpose of the 2-minute drills is to bridge the gap between didactic and clinical learning. Implementation of an Observation Guide and the 2-minute drills were designed to engage the student observer and modify simulation in order to accommodate large numbers of students. These methods contribute to meeting challenges faced by nurse educators.
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Chapter 1: Overview of the Research Study
Currently, nurse educators are challenged with integrating technology in teaching, providing students with diverse clinical experiences, and providing learning opportunity throughout the lifespan (NLN, 2008). Barriers associated with these challenges include the nurse faculty shortage, lack of clinical facilities, and increased class size. Specifically, limitations associated with clinical placement sites have contributed to the challenges nurse educators face with placing students in clinical facilities which offer adequate clinical experience. Shorter hospital stays for patients and limited clinical hours related to faculty shortages are also significant factors (Curl, Smity, Chisholm, Hamilton, & McGhee, 2007).
Simulation-based learning (SBL) can alleviate some of the barriers associated with educating nursing students. Traditionally, SBL occurs in a simulation laboratory with groups of four to eight students, thus limiting the number of students who are able to actively participate in the learning experience (Jeffries, 2007; Nehring & Lashley, 2010). Generally, role assignments for students participating in SBL include primary nurse, secondary nurse, ancillary personnel, family member, and observer. Assumption of different roles did not influence student learning outcomes, but those in the observer role did not experience the level of collaboration experienced by others in the simulation (Jeffries, 2007). Therefore, Jeffries’ recommendation for engaging student observers guided this research study.
Introduction of Articles
Two manuscripts are offered related to use of simulation in nursing education and will be submitted to peer reviewed journals.The first manuscript, The 2-Minute Drills:
2
Incorporating Simulation into a Large Lecture Format, is a report on an innovative approach to simulation in a large classroom; the 2 minute drill was designed to promote integration of didactic learning with clinical application. This manuscript will be
submitted toClinical Simulation in Nursing. A letter of interest from the editor is included in Appendix B. The second manuscript, The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning, describes a research study
investigating the effect of an Observation Guide on learning outcomes in simulation-based learning.This manuscript will be submitted toNursing Education Perspectivesfor review and publication. A letter of inquiry is found in Appendix A.
2-Minute Drills:Incorporating Simulation into a Large Lecture Format
Simulation education is designed to enhance the development of the nursing students’ technical, clinical and critical decision making skills using patient care
scenarios. The 2-minute drills offer faculty the ability to create an alternative clinical experience to foster development of integrative thinking and clinical reasoning skills in a large lecture classroom. The 2-minute drills are a teaching strategy developed to further learning in context by providing immediate opportunity to apply didactic content to clinical practice (Benner, Sutphen, Leonard, & Day, 2010). The purpose of this innovative teaching strategy is supported by the Nursing Education Simulation
Framework (Jeffries, 2007) and is based on Chickering and Gamson’s (1987) principles of best practice in education.
During the 2-minute drills, simulation scenarios are utilized to teach and evaluate students without the potential of harm to a patient. Students participating in the 2-minute drills work in small teams of four. Each team is allotted 2-minutes to care for the patient.
3
While the team is taking care of the patient, student observers determine the next appropriate step to be taken in the nursing process. All students are involved in the
learning activity as both active and passive learners. The 2-minute drills are conducive to different learning styles and are used as an alternative to provide a quality clinical
experience similar to hospital-based clinical (Parker & Myrick, 2009).
The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning
This study examined differences in knowledge, self-confidence, satisfaction, and collaboration between baccalaureate nursing students using an Observation Guide when observing a simulated clinical experience (SCE) and those observers without an
Observation Guide. A standardized pre-recorded video clinical simulation was shown to students randomly assigned to two groups. One group of students utilized an Observation Guide while viewing the video; the second group of students had no Observation Guide. The findings from the study revealed a significant difference in satisfaction. Student observers with the Observation Guide were more satisfied with learning than students without the Observation Guide. There was no significant difference in knowledge, self-confidence, or collaboration between the groups. The results will be used to enhance outcomes of simulation learning. Additional information pertaining to the research protocol is included in the appendices.
4 Chapter 2 Manuscript # 1
5
The 2-Minute Drills: Incorporating Simulation into a Large Lecture Format Jamil Norman, PhDc, RN
Doctoral Candidate, University of Texas at Tyler Assistant Professor of Nursing
Grambling State University 1 Cole St. Grambling, LA 71245
318-274-2594 318-274-3491
Sharon Thompson, PhD, RN Assistant Professor of Nursing Tennessee Technological University
Kathy Missildine, PhD, RN, CNE Assistant Professor of Nursing
University of Texas at Tyler 3900 University Blvd.
Tyler, TX 75799 [email protected]
6 Abstract
Nurse educators are faced with the challenge of providing quality nursing education. Current nursing education curriculum contains fragmented learning in which didactic and clinical learning are separated. Increases in faculty workload, classroom size, and
decreases in clinical placement sites have increased the need for innovative teaching strategies to assist in bridging the gap between didactic and clinical learning. Time constraints make it difficult to provide traditional simulation-based learning (SBL) for large groups of students. This article describes the theoretical congruence, development, and implementation of the 2-minute drills, a teaching strategy that integrates lecture and SBL in a large classroom format.
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The 2-Minute Drills: Incorporating Simulation into a Large Lecture Format The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health centers on the challenges facing nursing education and discusses potential ways to transform the profession of nursing (IOM, 2010). The crisis in nurse educator availability is a major contributing factor in providing adequate learning experiences for nursing students (Curl, Smity, Chisholm, Hamilton, & McGhee, 2007). Nurse educator shortages have caused a dramatic increase in faculty workload, and the lack of clinical placement sites has negatively affected the preparation of student nurses for clinical practice (Curl et al., 2007; Evans, 2009).
The quality of preparation of nurses at the undergraduate level has been associated with the level of clinical competence and proficiency (Murray, Grant,
Howarth, & Leigh, 2008). Current research supports the use of simulation-based learning (SBL) in nursing education to improve critical judgment, skills performance,
competence, self-confidence, knowledge, and satisfaction with learning (Bambini, Washburn, & Perkins, 2009; Ironside, Jeffries, & Martin, 2009; Sears, Goldsworthy, & Goodman, 2010). One challenge associated with implementing SBL is accommodating a large number of student learners. Implementation of the 2-minute drills actively
incorporates SBL in a large classroom format allowing for the immediate application of didactic learning to clinical practice situations.
8
Background and Significance
In a national nursing education study, the Carnegie Foundation for the
Advancement of Teaching researched how schools of nursing educate new graduates for the profession. The authors of Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010) offer innovative recommendations that, if implemented, will transform nursing education. Among these, the recommendations to integrate didactic and clinical is important in this activity.
Didactic learning in the form of lecture is a teacher-focused, passive format conducted in a large classroom setting and focuses on cognitive learning (Di Leonardi, 2007). Benner, Sutphen, Leonard, and Day (2010) indicate that lecture centers on the transmission of information from the faculty to the student but often does not engage the student nor integrate classroom and clinical learning. Clinical learning is a student-focused, active learning format better suited to small groups (DeBourgh, 2011).
Mandated student/faculty ratios in the clinical setting compounded by the current faculty shortage make integration of these two approaches difficult. Clinical simulation is an attractive alternative (Hawkins, Todd, & Manz, 2008) but requires considerable preparation time, implementation time, and attention to the difficulties inherent in engaging large classes of students (Waldner & Olson, 2007).
Theoretical Framework
The Nursing Education Simulation Framework (Figure 1) provides the theoretical framework that supports implementation of the 2-minute drills in nursing education (Jeffries, 2005, 2007). Jeffries (2007) proposes that learning occurs through information processing, experiential growth, and sociocultural dialogue. The theoretical framework
9
consists of five components: teacher factors, student factors, educational practices, simulation design characteristics, and outcomes.
The 2-minute drills focus on educational practices of active learning, feedback, student/faculty interaction, collaboration, high expectations, diverse learning, and time on task, as recommended by Jeffries (2007). This teaching strategy accommodates student nurses who learn through moving, doing, touching, seeing, reading, observing, listening, and writing. These characteristics are typical of most learners, as students learn through a combination of learning styles and benefit from instructional design that encompasses more than one delivery format (Fountain & Alfred, 2009; Jeffries 2005, 2007). During the 2-minute drills, students are able to visualize problems, perform a quick history, complete assessments, document findings, and implement nursing interventions.
Throughout the drill students implement collaborative learning by working in teams. Students are involved in active learning and must work collaboratively within the team to achieve outcomes. High expectations are developed when students associate their assessment findings and proposed interventions with information presented in the didactic portion of the class. Student faculty interaction and time on task are
incorporated throughout the drill. Feedback is provided during debriefing as students reflect on the learning experience. The 2-minute drill approach engages both the active performers and passive observers throughout the learning activity and during debriefing.
Implementation of 2-Minute drills Preparation
The instructor develops objectives and a scenario that will encourage clinical reasoning and judgment. The scenario should reflect realistic clinical practice and begin
10
with a brief synopsis of the patient’s clinical presentation, and will unfold in response to
student assessment and interventions. The high-fidelity simulator is programmed to trend the unfolding scenario by changing assessment findings. The instructor describes changes that cannot be simulated such as rigid abdomen, edema, or level of consciousness. These changes can be written on an index card, but the students must perform the assessment to discover the findings. Equipment is kept out of sight to prevent cuing student actions. An enclosed cart could be developed to transport commonly used equipment and could be used in multiple 2-minute drills.
To begin the drill, students are assigned to small teams of four. The scenario is shared with all students via overhead projection and verbal presentation. Each team is allotted two minutes in the drill, and each team builds upon the findings of the previous team. Students are expected to use the nursing process and critically think throughout the 2-minute drills, working together to determine patient needs. As the team determines the appropriate steps to take, student observers contemplate the next appropriate action. Students are not expected to complete the nursing process in the 2-minute time allotment. Rather, the findings and interventions of one team are communicated to the next student team for continuation of care.
For example, in an oxygenation/circulation scenario, the first team begins by initiating a focused assessment and responding to cues provided by the simulator. Cues such as decreased saturation rates and increased blood pressure prompt students to
intervene. As one student recognizes an abnormal blood pressure reading another student may begin an initial history, starting with questions pertaining to high blood pressure. The next step may be to determine if the patient is currently on blood pressure
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medication. As information is gathered one student documents the findings on the board and assists the students in the role of nurse by looking through the patient’s chart. After two minutes, the next team will come forward and continue where the previous team left off. If the first group of students applied supplemental oxygen, the second group should evaluate the effectiveness of the intervention and plan additional nursing actions.
After all teams have participated in the 2-minute drills and the simulation scenario is complete, the faculty member facilitates the debriefing component of the learning activity, using three to four debriefing questions to stimulate discussion. Students are asked to describe the objectives they were able to achieve and discuss the main goal of the 2-minute drills. The students are encouraged to reflect on their ability to link didactic content to the simulated patient, as well as theiroverall performance and plans for improvement in the future.
Debriefing is considered the most important portion of the simulated clinical experience (Dreifuerst, 2009). Debriefing serves as a source of feedback on clinical performance during the 2-minute drills. The standards of best practices for simulation (INACSL Board of Directors, 2011d) indicate that effective debriefing incorporates evidenced based methodologies, yet there is a paucity of research pertaining to differing approaches during debriefing. Typically, debriefing is facilitated in a small group; however, during the 2-minute drills debriefing is facilitated with the entire class. Large group debriefing is based on time constraints and decreased number of faculty, yet adhere to criteria for standards of best practice (INACSL Board of Directors, 2011d).
The process for conducting the 2-minute drills adheres to the standards of best practice for simulation developed by the International Nursing Association of Clinical
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Simulation Learning (INACSL Board of Directors, 2011). The scenario is based on written learning objectives congruent with course content and encourages clinical reasoning and judgment (Benner, Sutphen, Leonard, & Day, 2010; INACSL Board of Directors, 2011a; Jeffries, 2007). Each student has an opportunity to be an active participant in a collaborative environment that encourages intradisciplinary teamwork (Chickering & Gamson, 1987; Jeffries, 2007). The instructor serves as facilitators of learning, guiding the student through the learning process. As the facilitator, the goal is to meet the learning objectives and improve student skill and clinical judgment (INACSL Board of Directors, 2011b, 2011c).
Student and Faculty Experience
This teaching strategy was implemented with a group of 52 baccalaureate nursing students in their first semester of nursing. As part of the learning activity, students
commented on the 2-minute drills and gave informal feedback. Overall, students and faculty were excited about the learning experience, reporting the experience increased the effectiveness and application of cognitive learning.
Students reported increased confidence in their ability to clinically reason and “think and organize their thoughts for action.” Students stated that the 2-minute drills made the lecture information “come alive” and helped them realize information “isn’t just
for a test, it is for a real patient.” During the debriefing phase one student commented “how much easier it is to think in your seat than it is on your feet” when providing care
for a patient. Students assumed material learned in lecture would be easily adapted in the clinical environment, yet when actually implementing the 2-minute drills students found the process of developing their clinical judgment to be more arduous. Students felt better
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prepared to act quickly and correctly in a real patient scenario as a result of the
experience. These remarks reflect the importance that this activity may have to bridge the theory/practice educational gap discussed by Benner, Sutphen, Leonard, & Day (2010).
Faculty reported that the students’ overall response to the learning activity was positive. As students progressed through the semester, their skills improved and the time required for each scenario decreased, allowing for more student participation. The time-to-completion was used as a measure of improvement over multiple scenarios. While the 2-minute drills were not used as a graded activity, content covered in the drills from the didactic portion of the class was included in the course exams.
Time allotted for the 2-minute drills is dependent on class size. In a class of 52 students, each student participated in a 30 minute time period. The pre-briefing
component lasted 10 minutes and the debriefing component was an additional 30 minutes. It required less than 1.5 hours to engage 52 students in the drills, compared to the usual 45 minutes to 1.5 hours needed for small group full-scaled simulation (Nehring & Lashley, 2010). It would have taken 19.5 hours for a group of 52 students to progress through a full-scale simulated clinical experience. The learning activity has the potential to decrease the time faculty spend rotating a large class through the simulation laboratory by implementing a collaborative format of simulation-based learning in the classroom.
Conclusion and Recommendations
The 2-minute drills incorporate both lecture and simulation-based learning in a large classroom giving students an opportunity to integrate learning for a “sense of salience” (Benner, Sutphen, Leonard, & Day, 2010, p. 114). The 2-minute drills are a
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clock to quickly and accurately assess the patient, develop and implement a plan of care, and discuss expected outcomes. This learning activity is student centered, collaborative and incorporates multiple learning styles. The 2-minute drills guide clinical reasoning from passive to active and enable the student to immediately implement knowledge gained in lecture into a clinical practice scenario.
Evaluation of the learning activity is essential to ground the 2-minute drills in Best Practices of Simulation (Board of Directors, INACSL, 2011). One recommendation is to compare learning outcomes from the 2-minute drills to full-scale simulation. If there are similar findings in knowledge, attitude, and skill the 2-minute drills would have the same learning implications as full-scale simulation but require less time.
15 References
Angel, B., Duffey, M., & Belyea, M. (2000). An evidence-based project for evaluating strategies to improve knowledge acquisition and critical-thinking performance in nursing students. Journal of Nursing Education, 39(5), 219-228.
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives, 30(2),79-82.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: Jossey-Bass.
Curl, E., Smity, S., Chisholm, L., Hamilton, J., & McGhee, L. (2007). Multidimensional approaches to extending nurse faculty resources without testing faculty’s patience. Journal of Nursing Education, 46(4), 193-195.
DeBourgh, G., (2011). Psychomotor skills acquisition of novice learners: A case for contextual learning. Nurse Educator, 36(4), 144-149.
Di Leonardi, B., (2007). Tips for facilitating learning: The lecture deserves some respect. The Journal of Continuing Education in Nursing, 38(4), 154-161.
Dreifuerst, K. (2009). The essentials of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109-114.
Evans, M. (2009). Solutions to the nurse faculty shortage: A response to the AACN. Medsurg Nursing, 18(6), 387-388.
Fountain, R., & Alfred, D. (2009). Student satisfaction with high-fidelity simulation: Does it correlate with learning styles? Nursing Education Perspectives, 30(2), 96-98.
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medical surgical graduate nurses’ perceived ability to respond to patient clinical emergencies. Journal of Continuing Education in Nursing, 40(11), 491-500. Hawkins, K., Todd, M., & Manz, J. (2008). A unique simulation teaching method.
Journal of Nursing Education, 47(11), 524-527.
The INACSL Board of Directors (2011a). Standard III: Participant objectives. Clinical Simulation in Nursing, 7(4S), s10-s11.
The INACSL Board of Directors (2011b). Standard IV: Facilitation methods. Clinical Simulation in Nursing, 7(4S), s12-s13.
The INACSL Board of Directors (2011c). Standard V: Simulation facilitator. Clinical Simulation in Nursing, 7(4S), s14-s15.
The INACSL Board of Directors (2011d). Standard VI: The debriefing process. Clinical Simulation in Nursing, 7(4S), s16-s17.
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington DC: National Academies Press. Retrieved from
http:www.nap.edu/catalog/12956.html
Ironside, P., Jeffries, P., & Martin, A. (2009). Fostering patient safety competencies using multiple-patient simulation experiences. Nursing Outlook, 57(6), 332-337.
Jeffries, P. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103.
Jeffries, P. (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nurses.
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simulation into a clinical foundations of nursing course: Student and faculty perspectives. InternationalJournal of Nursing Education Scholarship, 5(1), Art. 26.
Nehring, W., & Lashley, F. (2007). High-fidelity patient simulation in nursing education. Sudbury, MA: Jones & Bartlett.
Parker, B., & Myrick, F. (2010). Transformative learning as a context for human patient simulation. Journal of Nursing Education, 49(6), 326-332.
Sears, K., Goldsworthy, S., & Goodman, W., (2010). The relationship between simulation in nursing education and medical safety. Journal of Nursing Education, 49(1), 52-55.
Waldner, M. H., & Olson, J. K. (2007). Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship, 4(1), 1-14.
18 Figure 1
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Chapter 3 Manuscript # 2
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The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning
Abstract
The purpose of this study was to examine differences in knowledge, self confidence, satisfaction, and collaboration between baccalaureate nursing students (n = 121) using an Observation Guide (n = 62) when observing a simulated clinical experience (SCE) and those observers without an Observation Guide (n = 59). The study design was a
quantitative quasi-experimental pretest-posttest control group design, used to determine differences between the observer groups. A two way mixed ANOVA and independent t-tests were used to identify differences in learning outcomes between the students using the Observation Guide and those without a guide. Although no significant improvement in knowledge, self-confidence, or collaboration was noted between groups, students utilizing an Observation Guide reported significantly higher satisfaction with the
simulated clinical experience. Findings from the research study indicate implications for nursing education and research.
KEYWORDS:Simulated clinical experience, Observer, Observation Guide, Experiential Learning, Nursing Education
21
The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning
Nurse educators are challenged to stimulate students to become critical thinkers who can function in a dynamic and complex health care delivery system (Decker, Sportsman, Puetz, & Billings, 2008), but are limited by a shortage of faculty and lack of appropriate clinical placement sites (Curl, Smity, Chisholm, Hamilton, & McGhee, 2007). The National League for Nursing has called for reform in nursing curricula to better prepare new graduates to practice in an increasingly technological health care environment (NLN, 2008). In addition, the Carnegie Report (Benner, Sutphen, & Leonard& Day, 2010) calls for profound transformation in nursing education that focuses on integration of didactic and clinical knowledge for a sense of salience in clinical practice.
Simulation-based learning (SBL) is an active learning approach that has been increasingly used in nursing education to meet these challenges, providing structured clinical practice for groups of students and ensuring a variety of experiences, efficient use of faculty, and a safe environment for student learning (Alinier, Hunt, Gordon, &
Harwood, 2006; Birch, et al., 2007). There is a lack of understanding regarding how to enhance knowledge, collaboration, satisfaction and self-confidence of observers of simulation experiences. This study determined if learning outcomes can be enhanced for baccalaureate nursing students observing the simulation experience by the use of an Observation Guide. The research question is: When baccalaureate nursing students view a video recorded SCE, is there a difference in knowledge increase, self-confidence, satisfaction, and collaboration between students who use an Observation Guide and those who do not?
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Background & Significance
Nurse educators are challenged to meet the Institute of Medicine (2010) goal that 80% of practicing Registered Nurses have a baccalaureate degree by the year 2020 despite scarce faculty resources. According to the American Association of Colleges of Nursing (AACN, 2010), 52,115 eligible nursing students were denied admission to baccalaureate and graduate nursing programs in 2010. These students were denied entry due to lack of faculty (62.9%), insufficient clinical placement sites (66.8%), classroom size constraints, lack of preceptors, and budget restrictions (AACN, 2010). Murray, Grant, Howarth, and Leigh (2008) suggest that simulation is a useful educational tool that can help meet the challenges faced by nursing academia.
Simulation learning has been applied in aeronautics, military combat, and medicine for many years in order to allow students to practice in high risk situations without risk of harm to self or others (Rosen, 2008). Flight simulators are used to provide practice on specific skills and knowledge needed to safely fly an aircraft (Rheman, 1995). In medicine and nursing some of the earliest simulators were Mrs. Chase, the first doll designed for use in nursing schools in 1911; the first plastic skeleton in 1938, and Resusci Annie in 1960 (Nehring & Lashley, 2010; Rosen, 2008). These simulators were created to help health care professionals practice their skills without causing harm to patients. In medicine, schools of anesthesia pioneered the use of simulation when teaching
resuscitation and intubation. Two of the most widely used forms of task trainers were spinal models (92.5%) and central line models (81.4%) (Turcato, Roberson, & Covert, 2008). Modifications in anesthesia simulation include using high fidelity simulation for Anesthesia Crisis Resource Management (ACRM). The simulated clinical environment
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produces a learning environment that is conducive to teaching crisis intervention without risking the well-being of a human patient (Turcato, et al., 2008). In addition, one of the most significant contributions to simulation was the development of the first moderate-fidelity patient simulator, SimOne ®, the precursor of modern day simulators (Nehring & Lashley, 2010).
The main educational goal of SBL is to create a learning environment that will ultimately result in better outcomes in health care delivery (Decker, Sportsman, Puetz, & Billings, 2008). SBL is increasingly used in nursing education as a remedy for limited clinical experiences and inadequate numbers of faculty. Due to lack of availability of clinical placement sites and high student faculty ratios in traditional clinical settings, clinical learning situations are often inconsistent and insufficient to prepare a safe practitioner. SBL has been used as an adjunct to or substitute for clinical hours and provides students with an opportunity to experience uncommon but high risk clinical events (Alinier, et al., 2006; Parsh, 2010). The student has the opportunity to practice skills in a safe environment (Smith & Roehrs, 2009) which leads to a decrease in performance anxiety and may promote self-confidence and satisfaction (Bremmner, Aduddell , & Amason, 2008; Decker et al., 2008; Medley & Horne, 2005). Incorporation of SBL has also translated into improved clinical judgment and skill performance
(Bambini, Washburn, & Perkins, 2009; Jeffries & Rizzolo, 2006).
The controlled environment of a simulation laboratory has the potential to increase communication skills which can result in safer clinical practice and improve interdisciplinary problem solving (Ironside, Jeffries, & Martin, 2009; Kameg, Clochesy, Mitchell, & Suresky, 2010; Sears, Goldsworthy, & Goodman, 2010). One of the leading
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causes of sentinel events in the clinical setting is a breakdown in communication between health care professionals (Dillon, Noble, & Kaplan, 2009). The Institute of Medicine report To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999) recommended the use of SBL to reduce errors in the clinical setting by enhancing communication and safety skills. Interdisciplinary simulation can also contribute to error reduction by improving the communication of health care team members and promoting experiential learning (Dillon, Noble, & Kaplan, 2009).
Student learning has improved when using SBL over other methods of learning (Brannan, White, & Bezanson, 2008; Howard, 2007). Alinier and colleagues (2006) and Brannan and colleagues (2008) demonstrated significant improvements in cognitive knowledge and clinical performance of students participating in SBL in comparison to traditional lecture. In a comparison of traditional and simulation clinical experiences, Schlairet and Pollock (2010) demonstrated small but significant increases in knowledge following both experiences.
Debriefing, a time of reflection following the active learning experience, is a critical component of SBL (Boet, et al., 2011; Heukelom, Begaz, & Treat, 2010; Kardong-Edgren, Starkweather, & Ward, 2008; Nehring & Lashley, 2010). Debriefing enables the student to reflect on and conceptualize learning (Kardong-Edgren, et al., 2008) and allows students to express thoughts and feelings without fear of repercussion (Nehring & Lashley, 2010). Faculty facilitate debriefing using a structured format enhances clinical reasoning and knowledge acquisition. This process enables the student to focus on learning objectives and foster reflective learning while enhancing clinical reasoning that will transfer knowledge into clinical practice (Nehring & Lashley, 2010).
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Gordon and Buckley (2009) reported that practicing nurses demonstrated improved self-confidence following simulation exercises, an improvement that participants credited particularly to the debriefing phase of the simulation. Differing approaches to debriefing may not affect learning outcomes. No significant differences were noted in two studies on debriefing styles of self-versus- instructor debriefing and in-simulation versus post-simulation debriefing (Boet et al., 2011; Heukelom, et al., 2010).
In general, SBL is conducted using a single faculty member with groups of four to eight studentswho are eachassigned a specific role (Jeffries, 2007). Some students are active participants in the role of primary nurse or secondary nurse; others may be
assigned more passive roles as family members, ancillary personnel, or observers. Little is known about the difference in knowledge acquisition among students in the various roles, specifically the role of observer. In a study on end-of life simulation (Fluharty et al., 2011), knowledge, self-confidence, communication skills, and satisfaction with simulation were evaluated in 370 associate degree, baccalaureate, and accelerated baccalaureate nursing students. There was no difference in knowledge gain between students in the primary nurse role as compared to observer role. Jeffries and Rizzolo (2006) explored differences in knowledge, self-confidence, judgment, and learner satisfaction based on simulation role assignment for 403 baccalaureate and associate degree students enrolled in their first medical-surgical nursing course. No significant differences were found in knowledge gain among students who were assigned to static mannequin or high-fidelity patient simulators. Regardless of the type of simulation, students in the observer role rated themselves lower in clinical judgment and
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should provide a means to engage students in the observer role to increase collaboration . Observation forms given to students prior to the experience might fulfill this need
(Nehring & Lashley, 2010) but there is a lack of robust research evidence on the effect of this approach on learning outcomes.
The purpose of the current study was to determine if there were differences in learning outcomes, including knowledge increase, self-confidence, satisfaction, and collaboration between baccalaureate nursing students using an Observation Guide when observing a simulated clinical experience (SCE) and those observers without an
Observation Guide. If learning outcomes could be improved by the use of an observer guide, simulation learning experiences would be more efficient and effective.
Theoretical framework
Kolb’s Theory of Experiential Learning (1984) was used as the theoretical basis
for the study. Kolb states that “learning is the process whereby knowledge is created through the transformation of experience” (1984, p. 38). Kolb (Figure 1) proposed that
experiential learning requires concrete experience, reflective observation, abstract conceptualization/analysis and active experimentation. All of these experiences are provided in SBL; therefore, experiential learning provides a theoretical framework for the process of embedding SBL within nursing curricula (Waldner & Olson, 2007).
According to Kolb (1984), learning is considered to be a continuous process in which knowledge is created by transforming experience into existing cognitive
frameworks, changing the way a person thinks and behaves. Experiences are grasped through either apprehension (participating in actual experiences) or comprehension (abstract conceptualization). A significant aspect of learning in experiential learning
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theory is the transformation of experiences. Transformation occurs through either an internal process of reflection on an experience (intention) or an external process through active experimentation (extension). Learning can occur at any of the four points in the cyclic process.
Experiential learning directly relates to the role of observer in which students participate during SBL. In this study, the learner was the BSN student who had previous knowledge gained from the lecture component and skills laboratory and observed the SCE. The concrete experience encompassed the simulated experience in which students observe a pre-recorded video simulation. Reflective observation was utilized as the observer and guided observer students learn through active observation of the students in the role of nurse throughout the simulation. Students achieved abstract conceptualization by using critical reasoning and reflection to evaluate the performance of the students in the role of the nurse. Guided observers utilized a written Observation Guide to assist in reflection and integration of their observations into a cognitive framework and the observers reflected and integrated without the assistance of an Observation Guide. The students referred to these observations during simulation debriefing to enhance abstract conceptualization. Active experimentation encompassed the debriefing phase of the SCE where guided observers and observers used the learning gained from observing the video recorded SCE to solve problems related to the SCE. This phase can be extended as the students apply learning to clinical practice.
The use of an Observation Guide aids in the internal process of transformation (intention) of a cognitive framework which occurs when the experience is integrated into the pre-existing cognitive framework through observation, conceptualization, and
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experimentation. Kolb’s theory postulates that the essence of learning is in the way the learning experience is processed. Learning begins with the experience and is processed through reflection, then is applied through action. The Observation Guide was designed to enhance reflective observation and abstract conceptualization.
Method
A quantitative quasi-experimental pretest-posttest control group design was used to determine differences between the observer groups and guided observer groups of baccalaureate nursing students after watching a video recorded Simulated Clinical Experience. Approval of the multi-site study was providedby all participating institutions. A convenience sample of 121 baccalaureate nursing students from four universities participated in the research study. Students enrolled in the fundamentals of nursing course at each university were eligible to participate. Universities were chosen based on similarities in program design and mission. In addition, clinical practicum experiences did not occur until after the research intervention had been implemented. Although each university had a simulation laboratory, a video recorded SCE and debriefing led by the primary investigator (PI) was implemented for consistency and control of the research intervention
Data Collection Procedures
Prior to viewing the SCE, students completed the Elsevier/HESI pretest exam followed by viewing a pre simulation briefing. Pre-simulation briefing included a 10-15 minute introduction of the simulated clinical scenario and discussion of the Observation Guide for the intervention group. Students were encouraged to make written comments on a blank sheet of paper or on the Observation Guide throughout the simulated scenario. Each group then viewed a pre-recorded video SCE (20 minutes) run by an experienced
29
simulation coordinator depicting two students, one in the role of primary nurse and one in the role of secondary nurse. This recording was shown to both groups, and provided consistency in the simulated experience. After the SCE each student participated in the debriefing component (30- 40 minutes) of the SCE. Debriefing was facilitated by the PI and consisted of nine open ended questions to encourage student reflection and abstract conceptualization. Following debriefing, each student completed the EPSS and Student Satisfaction and Self-Confidence in Learning Scales and the posttest Elsevier/HESI exam.
Instruments/Measures
A custom 30 item HESI™ parallel pretest and posttest was used to assess student competency. The exams measured the constructs essential for entry level practice, customized to test specific content related to the simulation scenario and matching the test blueprint. Content included medication administration/dosage calculation, safety, infection control, vital sign assessment, basic health assessment skills, and
communication. The content validity for the Elsevier/HESI was established by expert nurse educators and clinicians for each test item. Reliability for the custom 30 item parallel pretest/posttest exam was established by item analysis and measurement of pretest (KR20 = 0.48) and posttest (KR20 = 0.63).
The National League for Nursing Educational Practices in Simulation Scale (EPSS) measures four educational practices; active learning (items 1-10), collaboration (items 11 & 12), diverse ways of learning (items 13 & 14), and high expectations (items 15 & 16). This 16-item instrument is scored on a five-point Likert Scale. Factor analysis on the instrument was used to classify the seven principles of best practices into four
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categories. The instrument is used to determine if specific educational practices were present in the simulation and the importance of each to the student learner. Jeffries (2007) reports reliability for the instrument was 0.86 Cronbach’s alpha. The reliability for this study was Cronbach alpha 0.92.
The Student Satisfaction and Self-Confidence in Learning Scale is a 13-item instrument on a five-point Likert Scale. Five items on the scale (1-5) measure student satisfaction with simulated learning and the remaining eight items on the scale (6-13) measure student feelings of confidence in knowledge and skills of patient care. Content validity was established by nine experts (Jeffries & Rizzolo, 2006). Reliability for the instruments ranged from 0.87- 0.94 Cronbach’s alpha. The reliability in this study for the Satisfaction Scale was 0.93 and for Self-Confidence it was 0.87.
The Observation Guide was developed by the researcher to direct student attention to six specific aspects of the simulation. The components of the guide (assessment, clinical judgment, nursing interventions, communication, safety, and teamwork) are based on the learning objectives for the experience and the nursing process. Students used the Observation Guide to direct critical reasoning and reflection during the SCE.
Results Sample
Demographic characteristics for the sample are outlined in Table 1. The sample consisted of a total of 121undergraduate nursing students from four universities of which 119 completed the demographic information. Of 119 students, the age range was 18 to 46 years of age, with a mean age of 22.64 years. The total sample included 92 (77.3%)
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Caucasian, 14 (11.8%) Black, 6 (5%) Asian, 3 (2.5%) Hispanic, 3 (2.5%) other, and 1 (0.8%) multiracial students. Of the total, 84.9% (n = 101) were female and 15.1% (n =18) were male. The majority of the students had no previous medical or nursing experience (77.3%) and the highest level of education was a high school diploma (63%). The
sample was randomized into two groups; the experimental group (n = 62), which received an Observation Guide and the control group (n = 59), which did not receive an
Observation Guide. Data Analysis
A two-way mixed ANOVA was used with pretest vs. posttest as a within subject variable and guided vs. non-guided observation as a between subject variable to
determine the change scores in knowledge on the Elsevier/HESI pretest posttest
examination. Statistical analysis was performed using SPSS 17.0 statistical software. A total of 121 students participated in the pretest and posttest HESI examination. The pretest mean HESI score for the students with an Observation Guide (n = 62) was 814.01 (SD = 156.26) and 787.55 (SD = 152.88) for students without an Observation Guide (n = 59). The posttest mean score for the students with an Observation Guide was 719.95 (SD = 171.68) and 666.14 (SD = 169.53) for students without an Observation Guide. Both groups’ overall mean posttestscores were lower than the pretest mean scores. The results of the interaction effect indicate that knowledge change was not significantly affected by the type of observation in simulation, F (1,119) = .705, p = .403 (table 2).
Differences in Satisfaction, Self-Confidence, and Collaboration
Independent t tests were used to determine the differences of satisfaction, self-confidence, and collaboration between students with an Observation Guide and the
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student without an Observation Guide. Overall, students were satisfied with their current learning during the simulation activity. With a potential range of 5 to 25, students with an Observation Guide were more satisfied (M = 22.11, SE .34) than students without an Observation Guide (M = 20.51, SE = .55). There was a significant difference between the groups (t (117) = 2.518, p = .013), although effect size was small (r = .05). There was no significant difference in self confidence in learning between the groups (t (117) = 1.507, p = .134). With a potential range of 8 to 40, the students with an Observation Guide had a mean score of 33.93 (SE = .49) and the students without an Observation Guide had a mean score of 32.59 (SE = .75). On average, for the Educational Practices in Simulation Scale students with an Observation Guide had a mean score of 1.46 (SE = 1.07) and students without an Observation Guide had a mean score of 68.21 (SE = 1.71). This difference was not significant (t (117) = 1.640, p = .104) (Table 3).
Discussion
The findings from the study revealed that students with an Observation Guide were more satisfied with learning than students without a Guide. Satisfaction with
learning is an important aspect of SBL and has been associated with student performance (Bremner, et al., 2006). Students who are satisfied with their learning are more likely to actively engage and participate in the learning activity (Smith & Roehrs, 2009). Kolb’s Experiential Learning Theory (1984) supports the research findings on student
satisfaction. Students using the Observation Guide were more satisfied with the simulation activity than students without a guide. The Observation Guide was used to direct the student’s attention toward critical elements in the SCE, which may have increasedstudent satisfaction for participants with an Observation Guide.
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There was no significant difference in self-confidence between the groups, indicating that both groups felt self-confident and trusted their knowledge of self-care. Research would suggest that if there was a significant difference in satisfaction among the groups then self-confidence would show a parallel effect. Levett-Jones, et al., (2011) suggest that student satisfaction fosters self-confidence. In addition, there was no
significant difference in collaboration between the groups. The Observation Guide was used to engage students in collaborative work during the learning experience. During the informal group session students from both groups revealed that the debriefing component helped them “learn from each other” but it was difficult to discern the impact of the
Observation Guide on collaboration.
There was no difference in knowledge increase between student with an
Observation Guide and those without an Observation Guide. In fact, posttest scores were lower than pretest scores in both groups and across all research sites. These findings were unexpected, contradicting findings of previous studies of the positive effect of simulation on knowledge acquisition (Jeffries, 2007; Schlairet & Pollock, 2010). Only Hicks, Coke, and Li (2009) reported decreased posttest scores.
Therefore, an informal group of student participants at one of the larger universities was organized to gather additional information regarding the obscure statistical data. These students reported that the information on the pretest and posttest was not congruent with the material on the video recorded simulation, stating “it seemed like the test didn’t measure what we learned in the video.” Students stated that the pretest
and posttest were too general. One student referred to a question on foley catheterization and stated that catheterization was not in the video recorded simulation. The students
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may not have realized the link between infection control and catheterization inferred in the question. Although the pretest and posttest examined concepts related to the recorded simulation, the clinical situation differed. Students may have lacked the ability to apply conceptual and factual information to new and different clinical scenarios (Benner, Sutphen, Leonard, & Day, 2010).
Environmental factors might also explain the findings. Students stated that poor posttest scores could have been related to fatigue and hunger and that they hurried
through the posttest so they could eat lunch. Students believed that 30 test items for both the pretest and posttest were too long. Technical issues associated with security measures of the test were also considered an issue by some students. One student stated that “login issues with HESI contributed to the problem.” Technical issues increased the time
students participated in the research study and may have contributed to students hurrying through the posttest examination.
Limitations
This study used a convenience sample from four universities. The findings should be generalized with caution to the large population of baccalaureate nursing students. Since students were able to volunteer to participate in the research study there could have been an increased probability of recruiting individuals who were self-motivated to
participate in the research study, which could have affected the research outcomes. To decrease selection bias the research study sample was selected from four universities and students were randomly assigned to the control group (without an Observation Guide) or intervention group (with an Observation Guide).
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In addition, study limitations included possible threats of history, testing, instrumentation, and selection bias. Participants signed consent forms which address confidentiality of the SCE, but could have discussed elements of the simulation scenario with other students. To decrease history as a potential threat to validity, first semester nursing students were selected to participate in the research study due to their limited contact with human patient simulators. The threat of testing to validity was addressed by implementing a posttest that was similar in design to the pretest content, but not exactly the same. The use of different versions might help to explain the different scores for pre and posttest.
Implications for Future Research
The findings from this study indicated that students with an Observation Guide were more satisfied with the simulation activity than students without an Observation Guide. Although the intervention did not yield significant findings in knowledge, self-confidence or collaboration, further nursing research is warranted. First, replication of the study with advanced level learners who have developed testing skills for contextual learning would minimize threats in testing. Second, development of an instrument designed to measure student collaboration is suggested. Use of an instrument that measures four education practices including active learning, collaboration, diverse ways of learning, and high expectations, may not have adequately measured the single
component of collaboration. Third, measuring clinical reasoning in student observers with and without an Observation Guide will provide vital information pertaining to the student’s ability to reason while in the observer role. Lastly, further research on student
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observers is recommended to meet the challenges of clinical placement and increased enrollment.
Conclusions
SBL is an important aspect of student learning that provides a standardized and consistent clinical experience for nursing students. Research indicates that learning in a safe environment contributes to application of knowledge and skills that can be
transferred to the clinical setting (Lasater, 2007). Due to the challenges faced by nurse educators such as decreases in clinical placement sites and increased student enrollment, improvements in implementation of SBL for student observers are warranted.
37 References
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42 Figure 1
Kolb’s Theory of Experiential Learning
The concrete experience encompasses viewing the pre-recorded simulated clinical experience in which the student in the role of guided observer and observer involve themselves in a new experience. Reflective observation encompasses the student in the role of guided observer and observer reflecting upon and observing the SCE from two different perspectives, with an Observation Guide and without an Observation Guide. Abstract conceptualization encompasses critical reasoning and reflection in which the student in the role of guided observer will use an Observation Guide to integrate their observations into a cognitive framework and the student in the role of observer will integrate their observations into a cognitive framework without an Observation Guide. Active experimentation encompasses the debriefing phase of the SCE where the students in the role of guided observer and observer use the cognitive framework gained from observing the video recorded SCE to solve problems related to the SCE (Kolb, 1984 & Waldner& Olson, 2007).
Concrete Experience (Recorded SCE)
Reflective Observation (Role of Observer & Guided
Observer in SCE)
Abstract Conceptualization (Role of Observer & Guided Observer
in SCE) Active Experimentation
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Table 1
Demographic Information (n = 119)
Variable Frequency Percentage
Gender Male 18 15.1 Female 101 84.9 Age 18-23 97 81.5 ≥ 24 22 18.5 Race/ Ethnicity Caucasian 92 77.3 Black 14 11.8 Asian 6 5 Hispanic 3 2.5 Other 3 2.5 Multiracial 1 0.8 Education
High School Diploma 75 63
Technical School Graduate 1 0.8
Associate Degree 30 25.2
Baccalaureate Degree 13 10.9
Previous Medical Experience
